Documentation of a risk factor(s) for drug-resistant pneumococcus. For the purposes of the Pneumonia Measures, the risk factors are:

Patients 65 and over

ICU Patients – within 24 hours of arrival

Alcoholism – any mention in chart

Systemic antibiotic therapy in the last 3 months prior to arrival

Medical co-morbidities.

Exposed to child in daycare

Injection drug user – only illicit drugs

Suggested Data Collection Question:

Did the patient have a documented risk factor(s) for drug-resistant pneumococcus?

Format:

Length:

1

Type:

Alphanumeric

Occurs:

1

Allowable Values:

Y (Yes) There is documentation the patient had risk factors for drug-resistant pneumococcus.

N (No) There is no documentation the patient had risk factors for drug-resistant pneumococcus or unable to determine from medical record documentation.

Notes for Abstraction:

For the purposes of this data element, medical co-morbidities are defined as:

Renal, heart, lung or liver disease documented within the last 3 months

Diabetes mellitus

Asplenia

Malignancies documented within the last 3 months

For the purposes of this data element, ‘Exposed to child in daycare’ would consist of living with a child who attends daycare or working at a daycare. Casual contact or visiting a family with a child who has been in daycare is not considered “exposure.”

Suggested Data Sources:

History and physical

Nursing notes

Progress notes

Physician’s notes

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

Alcoholism

Alcoholic

Alcohol abuse

Asplenia

Diabetes

Diabetes Mellitus

IVDU

IV user

Malignancy - current

See Appendix C, Table 2.1 for a comprehensive list of antimicrobial medications

“History” or “H/O” for malignancies unless there is also documentation the malignancy was present within the last 3 months.